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Clearing up the confusion: are nurse practitioners an appropriate primary care solution?


Recently there have been comments on this website and in other forums about nurse practitioners in the health care system and how we are not really an appropriate solution to primary care shortages for a whole bunch of reasons. While debate is usually healthy, the problem here is that many of the rationales given for not utilizing NPs in primary care are just not true: “NPs need to be supervised by doctors.  Because NPs don’t own their own practices, they lack career-long commitments to our patients.  NPs are cheaper, but not really a cost saving because they don’t see as many patients.  And NPs spend longer with patients, and this makes them inefficient, not comprehensive.” Yikes – where do I start?!!!

Fallacy number one: NPs are supervised by physicians. No, we’re not. We do consult physicians when appropriate and when required by the crazy system of restrictions imposed on NP practice by the Ontario government, primarily at the behest of the physician lobbyists who from the beginning pushed for highly restricted NP practice.

For example, NPs are not allowed to order a bone mineral density test to look for osteoporosis. This is a test that uses so little radiation the technicians can stay in the room while the test is being done! How does prohibiting NPs from ordering this test serve patients?  We can order x-rays of the knees, but not the hips. We can order ultrasounds of the abdomen, but not the shoulder. Until recently, we could only order blood tests from an approved list which allowed us to order, as an example, serum amylase (a pancreatic enzyme) but not serum lipase (a pancreatic enzyme). Only recently have restrictions been removed to allow us to prescribe medications for common conditions such as diabetes and hypertension. If all these restrictions don’t represent built in inefficiency, I don’t know what does.

Fallacy number two: NPs lack career-long commitments to their patients and tend to move around a lot. I inherited hundreds of my patients from the practices of two family doctors who left the community. The second had inherited many patients from the first, and stayed only two years!

Now the part about NPs being mostly salaried employees is true, and this is because the Ontario government allows essentially no other compensation mechanism for us. Unlike physicians, we cannot bill OHIP for the work we do.

The fee for service model does, as another commentator points out, reward high volumes of patients, which does not necessarily result in good quality care. I have seen patients whose lab tests confirm they have had diabetes for years, who have had no idea about that because it was never explained to them – or at least never explained in a way that allowed them to understand it. I have seen parents who are astonished when I ask them to undress their babies for a check up. They tell me “our old doctor never did that.” I guess doing a well baby visit without removing the baby from the snowsuit could be perceived as efficient, but you’d be hard pressed to call it comprehensive.

Fallacy number three: NPs are inefficient because they spend more time with patients. Now, I can understand why this would be important if NPs put together cars on an assembly line. But how did spending more time with patients become a health system liability? I see patients in 20 minute appointments (more for annual health exams and well baby/child visits). My physician colleagues book 15 minute appointments – so we’re in more or less the same ballpark. I need longer appointments because unlike the doctors I work with I do not have nursing assistance, I work out of one examination room only, I clean up the room between patients myself, and I need time to consult on ordering tests the government restricts me from ordering independently. (My physician colleagues will be ecstatic when these impediments to practice are finally removed).

I believe most family physicians provide excellent care, although the ones I’ve worked with over the years have tended to either be on salary in the community health centre system, or to book long enough appointments to be able to spend adequate time with their patients.  I cannot comment on the high volume, book every five minutes style of practice doctors.

What I do know is that despite the government-imposed restrictions on our practice, NPs also provide excellent primary health care to thousands of Ontarians. Just ask our patients.

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26 comments

  1. Ada

    I have a fantastic nurse practitioner, Donna, I have been seeing since about 2008, in the town of Rosseau, Ontario. Donna is competent, professional and thorough. She explains various options and alternatives and most important she is dedicated to what is best for patients and does not push drugs. So, from my personal experience KUDOS to nurse practitioners, I think they are wonderful.

  2. Joanne Gordash MN NP

    Excellent comments Kathy. It will be amazing to see what NP’s can accomplish when we are finally unfettered by the various politically motivated obstacles. I say, lets let the patients decide who best serves their needs. As for time spent in consultation with patients, we do spend more time with clients, teaching, liaising, making referrals and co-ordinating several aspects of care in one visit. But, it this way, the individual leaves more knowledgable, empowered, connected, and less likely to need a succession of follow up visits to manage the concern.

  3. Mark MacLeod

    In a context of team, I agree. In the context of autonomous silo, current opinion would suggest no.

  4. Realist

    Thank you for keeping the discussion going. NPs play a key role in a multidiscuplinary health care team. Their skills assessing, teaching counselling and accessing resources for patients are excellent. But they are not a silo. And more important, they can’t be. Like it or not, physicians’ training is more comprehensive and their ability to quickly assess a patient’s condition is required in a system where demand will always exceed supply.

    NPs skills are used most effectively when they follow a patient population, building rapport with patients and providing the support patients need to self manage. NPs’ skills are not ideally suited for much acute episodic care, where quick assessment and diagnoses are required. I am not saying they absolutely cannot do this, but the strength of the nursing role is not here.

    Yes, some physicians give up their practices. But becoming a family physician and taking on a practice is by design a career and personal commitment, for many docs, beyond typical retirement age. Financial and personal investment is a condition of the work for most docs. This simply is not the case for NPs.

    NPs are a tremendous resource in the system. It is incumbent on us to use the resource wisely. NPs are not and should never be considered a replacement for physicians. Nor should they replacements for dietitians, pharmacists or socail workers. We have an opportunity in primary care to celebrate the addition of NPs to the primary care team. Let’s not miss that opportunity by getting into a turf battle.

  5. Jordan, pharmacist

    As a pharmacist with experience working with both primary care NP and GP. There is opportunity to leverage the strengths of both roles. NP rate higher on the scale of collaboration, take the time to collect as many pieces of information including the input of allied health; GP rate higher when it comes to speed of quality decision making built, in many ways, as a product of the system they work within. Both are having challenges treating elderly medically complex patients. How does a turf battle arise when there is so much work for everyone to do?

  6. Charles

    Interesting discussion.

    Firstly, I’m curious about who is held legally accountable should adverse events arise.

    Secondly, with respect to the value of NP vs. MD for specific primary care presentations, is there data on patient outcomes? (e.g. Patient satisfaction but also other hard measures of effectivenss such as BP control, adherence to medications, glucose control). Economic evaluations when possible would also be very informative. It seems as though there is a lot of anecdotal evidence to feed the debate but without an actual comparison of patient outcomes I’m not sure we will make the most of efficient use of the strenghts of NPs.

    • NP student

      A summary of the role and quality of NP practice, with outcomes measures of NP unique interventions to patient care is nicely put into a presentation by R Kleinpeel Phd RN FAAN FAANP( link below).
      It is unfortunate that there is so much resistance to the acceptance of the NP not as MDs equivalents but as their valued partners… This is in part due to lack of mass education of the competencies, education and scope of NP practice.

      There is abreast of evidence-based data actually showing that in chronic disease management the NP interventions are more successful than those of MDs due to the time and education factors.

      NPs have an unique role in patient care as proficient medical practitioners with broad nursing expertise.

      Assessing Outcomes in NP Practice – AANP Find A Nurse Practitioner
      aanponline.org/2009ConfHandout/2009_PDF/9_2_20.pdf

  7. Leah

    I worked in the US namely florida as an NP in a general practice office. Our responsibilities were to provide patient care in the clinic setting, as well, our time was spent on call and taking part in home visits from a Doctors and NP housecall service. I saw more patients during housecalls than in the office per se.\

    Can this happen in Ontario? Do you think it can be a trend, since the lack of doctors for home visits is emergent..Most of our elderly and young patients who dont have access to medical service when they actuelly need it is unbelievable.

    Can NPs bill OHIP or would you see this privatized in any way?

    How can we help the growing elderly population that wishes to stay at home with relatives, and help those families recieve the medical care they deserve?

  8. kathy hardill

    Leah – you raise some interesting points – NPs in ontario cannot bill ohip, but i don’t think the answer is private fee for service either – in some Local Health Integration Networks or LHINs, ministry of health funding has been earmarked for services such as having mobile travelling NPs available in the evenings to see long term care residents rather than sending them to ERs – so i suppose if a particular need was identified, say, regarding frail home-bound seniors who are not receiving primary care, a program dedicated to them could be fleshed out and potentially funded that way – again, ministry of health would likely see it as beneficial to keep those folks out of emergency rooms – as well, some primary care funding models, such as community health centres and family health teams and nurse practitioner led clinics have more flexibility to respond to specific community needs because they have salaried staff, to create programs like home visits to seniors etc if those needs are identified in a particular community

  9. Brooksbane

    I will be perfectly clear: I am very disappointed that any physician would consider nurse practitioners as effective primary care providers. I am also disappointed in our College of Family Physicians, who are willing to reduce primary care numbers just so they can be considered “specialists. The need for primary care is great, and because of the boneheaded delusion that family medicine is a specialty which forces medical students to NOT choose it for a career, a great gap in primary care exists. Enter nurse practitioners to fill this gap. We should all be very concerned about this turn of events.

    As physicians, our primary duty is to the patient in our care. It is not to the system, and it is not to the government. In fact, the reason physicians are remunerated well is because patients and the public trusts us to stand up for their health. By giving primary care over to nurse practitioners, we are effectively selling-out patient care, and are negating the trust we have worked so hard to maintain.

    Throwing out anecdotes about how some family physician didn’t explain to a patient about a new diabetes diagnosis is a cute story but does not justify further lowering our standards of primary care by allowing nurses to do it.

    You fail to understand that the reason you cannot order BMD tests is because your training in nursing is insufficient to ensure to the public that you understand why the test is ordered, when the tests needs to be ordered, and what to do with the results once you get them. The basic scientific understanding of health and disease taught in nursing training is nowhere near the appropriate depth and breadth to allow for independent medical practice.

    The only reason that this discussion is even occurring is money. Nurses want to be paid more, and that I do not disagree with – they are an undervalued part of the health care spectrum. But to practice outside of your scope to the detriment of patient care just for a few more dollars is not the right way to do it. We should also be very concerned about the powerful nursing lobby, who, once given an inch, will take a mile, patient-care be damned!

    • Primary care MD

      I could not agree more with Brooksbane.

      Ordering tests and bloodwork may seem attractive and make an NP feel knowledgeable but there are reasons that certain tests are not allowed to be ordered by them. If you don’t know why, it only serves to confirm that you shouldn’t be allowed to order them!

      There is much more to primary care than well baby visits and pap smears. Unfortunately cherry picking patients and having a roster of 300-500 patients would make anyone with basic medical knowledge feel clinically competent. However most full time docs like myself have a roster 4-5x that of an NP, and on a per-patient basis they are already getting paid more than us docs. It sounds like you know want the ability to bill OHIP? Wow

      If we give them the ability to order more tests where does it end? When will they acknowledge they are not doctors and be content with that broad scope they already have?

      • Proud Canadian NP

        Fight it you may, however, the role of the NP would not be emerging if the need wasnt there. We’re not competing with you so stop feeling threatened. Just move over and allow the patient to benefit from comprehensive inter professional care.
        NP

        • Steven

          I find it interesting how threatened and aggressive the physicians can be!
          I am guessing that these physicians leaving these malicious comments are older practicing ones, as I find newer GPs are more accepting and recognizing of an NPs ability.
          However, that said, you get both. I am currently an RN and enrolled in my MScN with NP and I know that, in my program a couple of my professors (older ones however) really believed in the antiquated hierarchy of medicine. Saying that Practical Nurses were “below” RNs and that MDs were “above” RNs. I feel this to be a very malicious and corrupt view to hold that not only harms your interactions with colleagues but harms patient care. If you are holding to view of “hierarchy”, thinking that those around you are less or more competent, you are bound to feel insecure and make more mistakes, as these feelings distract from the greater issue, the patient.
          This transcends into medical practice. Just looking at malpractice claims, how many times has an MDs error resulted in death in North America in the last year? A lot. (Now, it wouldn’t be fair to compare to NPs, as MDs see more acute and unstable patients that are already more at risk for dying). Now, how many times has a plane crashed causing deaths in the past year? Far less than the amount of MDs that have killed their patients. And in comes my point, some healthcare professionals are advocating the techniques used in aviation to be applied to healthcare, as aviation is one of the safest industries with an amazing track record. One attributable act that differs between aviation and healthcare is the formalities. Aviation views all of their crew as “integral to the safety and security of the aircraft”. That means, that no one person is viewed as being more important than the other. And look how well it is working for aviation? If only physicians would stop trying to prove to themselves that they are masters of the universe and be more humble then perhaps our poor unsuspecting patients wouldn’t die so much at their hands.
          Furthermore, this point is augmented by the blunt accusations from the MDs that NPs are “insufficient” to provide primary care, lacking the necessary skills needed to practice safely. Well, unfortunately there are a plethora of studies, with statistical certitinty, proving that, in some cases, NPs prescribed and practiced SAFER and more ACCURATELY than MDs. Why is this? Well, from what I am seeing, probably because NPs are more humble and able to admit when their wrong. All I see from those two posts from the MDs is pure egocentrism. Thinking that they know everything and that they are best equipped to handle everything. Now I can see where those studies are coming from. I would MUCH rather have an NP tell me he or she was “unsure” than have a physician say “well It’s this” without truely knowing.
          Also, it’s noteworthy to add that, I have only been practicing as an RN for just over 2 years, and in 5 circumstances picked up on something an MD missed, 2 of which were life and death situations. And I am not even an NP yet. So please, I urge you MDs to be more humble and accepting. We don’t know everything and you don’t know everything. It is important to understand all of our limitations and stop worrying about “who is better” because you are only harming your patients.

      • Holly Cabell

        Dear fellow providers,
        I work in the Emergency Department in the US. I order all the same tests as the physicians and interpret the results and decide on the dispos. I am not a physician “wanna-be”. In my 4th year of undergrad I considered studying medicine; however a 4th year professor advised against it as it would be a hell of a waste of a great nurse. I have my doctorate, I’ve attended University in Both US and Canada combined 11 years with an outstanding student loan of $160,000 American dollars. I use my title of doctor frequently explaining my doctorate is in nursing. I consult with other experts as needed and am treated as an equal team player in the hospitals I work. I do all procedures including spinal taps, suturing, I&D, reducing of fractures or dislocations, splinting. IInterpret EKG’s, Xrays, treat STEMI’s Strokes, intubate and on and on. Patients appreciate me and the Physicians appreciate me as well. They often ask me for my opinion. I have worked in the Emergency Room setting for 20 years now, 17 of which were nursing; learning from a wide variety of great physicians and 3 years as a provider. You cannot compare apples and oranges. Nurse Practitioners do not intend to compete with physicians, social workers, psychiatrists, religious leaders, educators etc. We are of a different philosophy; a combined philosophy. We are not focused on any one dimension, ie: physical, social, emotional, intellectual. We are not focused on illness alone; we focus heavily on wellness. We receive additional education as a nurse practitioner with an added medical focus with clinicals. Although it appears I do the same work in the ER as my colleagues, we work from a different philosophy; however a philosophy that ultimately results in excellent patient care. Nurse Practitioners compliment other professions in this and all other environments if allowed and when our profession is properly understood.

    • RigMedic

      First of all, Physicians do not choose primary care because it does not pay as well as being a surgeon or a specialist. So in my humble professional opinion no, the system does not FORCE medical students to choose family medicine, the majority do not choose it because surgery or being a specialist will pay off their student loans faster. Which, no one can really blame them for, I mean who does not want to get out of debt ASAP?

      Some physicians, do not do their job well, and in my opinion should be remunerated accordingly to their performance. There is more than just not thoroughly explaining diagnosis, but also the drugs. Docs sometimes think they know everything, but they really don’t. The doc I went to four years ago for a strep throat infection gave me Amoxicilin after I explicitly told him not to, because I suspected that I had an antibiotic resistance to that drug after having been prescribed it for chronic tonsillitis (lasting over a year) approximately 10 years ago.I wold like to note, that this is the clinic I always go to, and the antibiotics were prescribed by doctors at that clinic. In simple terms, he could have reviewed my file and confirmed my story, He did not, and he had the damned thing in his hand Guess what, after faithfully taking my course of antibiotics every 8 hours religiously, I was back for Clindomycin, because he did not listen, to which I made a point of making clearly obvious. If it had been a narcotic prescription, as a physician I admit I would have been suspicious, but literally no one asks for different antibiotics. I am pretty sure, had I gone to an NP, they would have reviewed my file and prescribed me something different, so I wouldn’t have been back in a week. Furthermore, another doc prescribed my grandma a medication for rheumatoid arthritis, and it almost killed her had I not told her to stop taking it, and I wasn’t even a medic at the time, I simply used my brain. The doc did not bother to check the interactions of the other pharmaceuticals he prescribed her. To be fair, Neither did the pharmacist who actually does know more about drugs than the doc, and gave her the two drugs at the same time. That being said, Trust is not a word that I personally, and professionally associate with Doctors at the moment, with the exception of my Dentist, and my Chiropractor. I am more likely to ask an RN or an NP for advice, and steer clear of MDs.

      The best part about being a medical professional, regardless of discipline is the fact that we all have brains and can build on our existing medical knowledge! WOW! who would have thought? NPs may not have sufficient training to order BMD tests, (Which I would like to note that in Alberta it is within an RN’s scope of practice to apply a cast, so They obviously have some training with regard to bones in general and would not be hard to build on that knowledge at all.) However, they can learn not only how to interpret the tests, but how to explain the tests to the general public in a way that can be understood. All health professionals regardless of discipline, need to essentially be able to explain procedures, tests and why, in their opinion is necessary for this procedure/treatment/test to occur. In case you didn’t know this, it is part of obtaining this little thing called ‘Informed Consent’ which is in every level of healthcare including standard first aid. Also, I would like to point out that you did not come out of your mother’s birth canal knowing everything you know now. Which, means, that you had to learn it.

      Lastly, there is this little thing called practical experience. When you as an MD diagnose a patient at the hospital, there are more than likely a few RNs on shift who learn, and remember what a specific condition presents with, same with Medics. They are the ones doing mostly all the primary care work in the hospital anyways, because the doc doesn’t have time to do it. When you order drugs, do you pop in the IV? Probably not, It’s a Nurse who does it. When you order epi do you give it? Probably not, it’s a Nurse who does. In my opinion Nurses have enough clinical experience to make up for this ‘lack of training’ that you speak of. In terms of lowering standards, that you so speak of when you seek care from an NP, In my opinion it is better than an MD anyways. At least they listen.

  10. Alana

    do np’s learn about bone structure? Also, they don’t deal with broken bones or bones overall right?

    • Steve

      Alana
      That’s a really random question but yes they do. They learn about bone anatomy and pathology and meyloid pathology and diagnosis such as myelopthisis, aplastic anemia, polycythemia, etc. They do learn and can manage uncomplicated fractures.
      I hope this answers your question.

  11. Metta

    Our doctor quit suddenly & I just learned today that my spouse and I are removed from the doctor wait list and permanently assigned a NP. I’m told we will never be assigned a doctor now. I’m healthy but, my spouse has skin cancer. Our last GP caught the latest malignant growth when it was missed by two skin specialists. Now that we will never be seen by a doctor, I worry the NP with far less training will put my spouse at risk.

    • Jessica

      Metta,
      That is wonderful that your GP caught the latest malignant growth. I would hypothesize that this is because he/she knew your family, and listened to your concerns. The dermatologist on the other hand most likely spent 5 minutes if you were lucky with your partner because they push an extremely large number of patients through per day.
      You state your concern with NP care is their ‘far less training’. I would like you to know that Medical school takes between 3-4 years, and then a family residency program an additional 2 years. In comparison a Nurse Practitioner does a 4 year Nursing degree, followed by 2 years of nursing work, at which point they can apply for the NP-Masters program (additional 2-3 year program). So if you do the math as you can see they do not have ‘far less training’.
      Depending on the model of care in which they work, NPs are usually given the luxury of more time with their clients (as our program has a strong focus on health promotion, and disease prevention… Which takes time). So I would say you and your spouse are fortunate to have an NP. I hope that once you meet with him/her, you will slowly gain trust that this is the case also.

  12. Susan

    If a physician is on sure a sting as a consult can the NP bill under the doctors billing number if the np is seeing patients . Are the patients to be rostered or not rostered to the physician . We are excited about have NP in our clinic but want to ensure we are doing things properly . Thank you

  13. Susan

    Sorry I dislike auto correct !!

    I meant to say a family doctor is on site at all times and available for consult . Can the NP bill under the physicians billing number . We are being very transparent to patient but not sure how the NP is allowed to be paid . We are fee for service
    Thank you

  14. Craig

    My personal experience dealing with a nurse practitioner certainly leads me to a much different opinion than the very high one you have of yourself. I went in for an appointment only a couple months after being diagnosed with degenerative disc disease and having surgery on my lower back. I was having severe burning from my neck thru both arms and numbness in most of my fingers. This highly trained and qualified medical professional repeatedly interrupted with ridiculous comments for example nearly every one has degenerate discs and very few really require any more treatment than some diet changes and some excercise. Now at this point I was 180lbs and 5′ 11″, at the high end of healthy if only using those two numbers. However when checked out by an actual MD that actaually bothered to look me over as opposed to checking boxes on her clipboard reveals I’ve higher than normal muscle mass. All of the other routine tests the MD performed came back showing me to be in excellent condition aside from my disc problems. The rest of the visit consisted of a rather insulting lecture on the overuse of narcotics and how she would never prescribe them to me, as they should be reserved only for terminal cancer patients. Not once did I ask for them, I also informed her to the fact I had not taken any since the first surgery. This only caused the lecture to start over again. The advise I left the appointment with was to loose 10lbs and to check in with addiction services for my drug problem. Not one test of any kind was ordered no physical examination of any kind done. These conclusions came purely from height and weight numbers not lining up on her chart and the stereotype that if someone says they are in pain and has previously taken narcotics they must be drug seeking. Now thankfully I was eventually able to locate an actual MD who was accepting patients. The first visit consisted of him looking up various parts of my medical history, a long conversation regarding my current issues, a fairly in depth physical exam, a prescription for meds to help with the nerve pain (not narcotic), a referral for phisio, reqs for full bloodwork and an MRI on the neck. I am currently waiting for surgery but between the phisio and mess I have been able to return to work and lead a fairly normal although restricted life. Based on my personal experience NP’s should have to consult with an MD for every patient requiring anything more serious than a flu shot. Better yet get rid of the NP all together. Let the MD’s diagnose and order treatment and leave the nurses to the routine front line care of in patients under the supervision of qualified MD’s.

  15. Natalie R

    Thank you for providing this information. I have been confused with respect to the role and responsibilities. I think I would rather have NPs as my primary care practitioner. Keep up the great work.

  16. Hiam

    This is really disappointed point in Canada.. I shame with my MD
    to visit office of abscent Physician then I ask to meet NP.
    not sure why Canada health system replacing physicians with NPH.
    Dozen experienced doctors struggling unemployment (playing thousands for liecence rxams rather than the struggles of intentional hard test to fail) you find NP replacing these position.

    If is so …shut down medical colleges and stop Img doctors to immigration to Canada. And replace them with nurses.
    It look like chiropractic when compared to orthopedics.
    Both have Dr title.
    Enough killing doctors emotionally
    They had dream and worked extremely hard..do not expect to what’s ever replacement.

  17. Jayne Douglas

    I’m thrilled to have an incredible NP after being without primary care in small town Ontario for the past 2 years. After living in the city all my life and having multiple specialists on several occasions, I can honestly say I feel in good hands with this extremely competent professional and have decided to stay with her knowing that a new family doc has arrived in town. He apparently was accepting applications for new patients to review rather than using the CareConnect lists for the area and I won’t speculate as to why he has to pick and choose his patients. I’m sticking with my NP who without a doubt has shown me she is as professional as they come when it comes to primary care. She has the ability to refer me to specialists if need be and is in a position to request tests, fill prescriptions, and take plenty of time to address all of my concerns … something my former doctors didn’t seem to have time for. Time to park egos and share great care!

  18. Meeno

    My nurse practitioner ordered a ultrasound on my shoulder no problem.

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